Abstract
Purpose
The superficial temporal artery (STA) is the principal donor vessel for extracranial–intracranial bypass, particularly the STA–middle cerebral artery (MCA) bypass. The present study aimed to characterise the topographic and morphometric anatomy of the STA common trunk and terminal branches, to establish surface mapping data for pre-operative planning, and to evaluate the suitability of terminal branches as bypass conduits in Vietnamese adults.
Methods
Fifty hemi-head specimens from 25 embalmed Vietnamese adult cadavers were dissected. Topographic relationships between the STA, adjacent neurovascular structures (superficial temporal vein [STV] and auriculotemporal nerve [ATN]), and craniofacial landmarks were documented. Terminal branching patterns, outer diameters at defined levels, branch lengths to the 1-mm diameter threshold, branch angulations, and the parietal axis angle were measured.
Results
All STAs arose posterior to the mandibular neck. Terminal bifurcation was present in 90% of specimens; the remaining 10% exhibited an anaplastic pattern. Among bifurcating specimens, the branching point was located above, at, and below the zygomatic arch (ZA) in 93.33%, 4.44%, and 2.22%, respectively. The common trunk lay 10.92 ± 4.14 mm anterior to the tragus along the lateral canthus–tragus line and 12.85 ± 6.26 mm anterior to the superior helix attachment. Mean outer diameters at the ZA level and immediately before bifurcation were 1.88 ± 0.40 mm and 1.76 ± 0.36 mm, respectively. At 70 mm from the ZA (working length), mean diameters of the frontal and parietal branches were 1.26 ± 0.25 mm and 1.11 ± 0.22 mm. Bypass suitability rates were 88% for the frontal branch, 68% for the parietal branch, and 62% when both branches were required.
Conclusion
The STA anatomy in Vietnamese adults is highly compatible with its use in STA–MCA bypass surgery. The topographic and morphometric data presented provide a practical basis for pre-operative surface mapping and intra-operative vessel preservation.
Keywords: Superficial temporal artery, Common trunk, Terminal branching pattern, Middle cerebral artery, STA–MCA bypass, Vietnamese adults
Introduction
The superficial temporal artery (STA) is one of the two terminal branches of the external carotid artery. It arises posterior to the mandibular neck, traverses the parotid gland in company with the superficial temporal vein (STV) and auriculotemporal nerve (ATN), and ascends superficial to the posterior root of the zygomatic arch (ZA), where it generally bifurcates into frontal and parietal branches [24]. Numerous cadaveric and radiological investigations have characterised STA anatomy for application in craniofacial reconstructive and aesthetic procedures [3, 17, 20, 22, 26]. Among these, Rusu et al. [23] characterised STA variations–including terminal bifurcation patterns and the pericondylar course of the artery—on CT angiography of 86 arteries. In Vietnam, Pham et al. [21] documented STA and STV characteristics relevant to scalp flap design, reporting moderate-to-good flap survival rates of 100% and 97.73% at 3 and 6 months, respectively.
Beyond its reconstructive role, the STA is the primary donor vessel in extracranial–intracranial bypass surgery, particularly the STA–MCA bypass, which improves cerebral perfusion in patients with Moyamoya disease—a condition characterised by progressive stenosis of the distal internal carotid artery and proximal MCA with basal vascular proliferation [6, 14, 15, 18, 19]. Comprehensive pre-operative surface mapping of the STA is essential for planning the skin incision and for protecting adjacent neurovascular structures during bypass surgery.
Population-specific data are required because significant inter-ethnic differences in STA morphometry have been reported [1, 2, 22]. To date, no comprehensive cadaveric study of STA anatomy specifically oriented towards STA–MCA bypass has been conducted in Vietnamese adults. In the present study, we aimed to characterise the topographic and morphometric features of the STA common trunk and terminal branches, to define surface landmarks facilitating pre-operative planning, and to evaluate the suitability of terminal branches as bypass conduits in a Vietnamese cadaveric population.
Methods
Study design and specimens
This cross-sectional, observational cadaveric study was conducted from August 2024 to April 2025. Fifty hemi-head specimens from 25 embalmed, formaldehyde-fixed Vietnamese adult cadavers were dissected. The mean post-mortem embalming (fixation) duration was 6.3 ± 2.1 years (range 4–11 years). Specimens were preserved by conventional formalin fixation (immersion in approximately 10% neutral-buffered formalin) and stored in the same solution at room temperature until dissection. Thiel soft-embalming, which better preserves vascular compliance, wall turgor, and external calibre, was not available at the participating institutions; all specimens therefore underwent conventional long-term formalin fixation, a constraint of the available cadaveric infrastructure. Cadavers were selected by convenience sampling from body donors at the participating institutions. Specimens were excluded if they exhibited craniofacial pathology, traumatic deformity, or prior craniomaxillofacial surgery. Each specimen was assigned a coded identifier (N/Y format, where N is the sequential donor number and Y the year of death).
Sample size calculation
The minimum sample size was estimated using the formula for a single mean: N = Z21₋α/2 · σ2/d2, where Z1₋α/2 = 1.96 (95% CI), σ = 0.49 mm (SD of STA diameter at parotid gland emergence, from Pham et al. [21]), and d = 0.15 mm (margin of error, representing approximately 6% of the mean STA diameter—a precision level considered clinically meaningful for bypass conduit selection). The estimated minimum was 40.99 specimens; 50 were included to ensure adequate precision. The variance estimate was drawn from Pham et al. [21], a doctoral dissertation formally defended at and archived by Hanoi Medical University and available on request; its reported SD of STA diameter (0.49 mm) is concordant in magnitude with peer-reviewed cadaveric series in comparable populations [2, 22], supporting its use for sample-size planning.
Dissection procedure
A standard question-mark incision was made beginning 10 mm below the ZA to the superior helix attachment. Using a surgical microscope (Takagi-M9), the STA, STV, and ATN were identified and meticulously exposed. The parotid gland was incised and the STA traced proximally to its origin from the external carotid artery. The terminal branching point and the courses of the frontal and parietal branches were carefully dissected.
Four craniofacial landmarks were defined: the midpoint of the tragus (point O), the lateral canthus (point A), the superior attachment of the helix to the scalp (point B), and the midpoint of the inferior orbital margin (point C). An Oxy coordinate system was established with the Ox axis running from O toward C (infra-orbital margin–tragus line) and the Oy axis perpendicular to Ox at O. All landmark measurements were performed with the cadaver head in the standard anatomical position (Frankfurt horizontal plane). Three reference lines were constructed: OC (infra-orbital margin–tragus line), OA (lateral canthus–tragus line), and AB (lateral canthus–superior helix attachment line).
Measured variables
Common trunk of the STA
The following variables were recorded: distance from the STA origin to the mandibular neck; topographic relationship and distances between the STA and the STV and ATN at the level of parotid gland emergence; distances from the common trunk to the tragus along the OC and OA lines; distance from the common trunk to the superior helix attachment along the AB line; lengths of the intra-parotid and extra-parotid segments; and outer diameters at the origin, parotid gland emergence, superior border of the ZA, and immediately proximal to the terminal bifurcation.
Terminal branching patterns
Branching patterns were classified following Marano et al. [12]:
Type A1 (classic): bifurcation into frontal and parietal branches with both original diameters ≥ 1 mm.
Type A2 (hypoplastic parietal branch): bifurcation with parietal branch diameter < 1 mm at origin.
Type A3 (hypoplastic frontal branch): bifurcation with frontal branch diameter < 1 mm at origin.
Type A4 (hypoplastic both branches): bifurcation with both branch diameters < 1 mm at origin.
Type B1 (anaplastic parietal branch): absence of bifurcation; common trunk continues anterosuperiorly to become the frontal branch.
Type B2 (anaplastic frontal branch): absence of bifurcation; common trunk continues posterosuperiorly to become the parietal branch.
The position of the branching point relative to the ZA (above, at, or below) was recorded, and its Oxy coordinates were determined for specimens with a discernible bifurcation (types A1–A4).
Frontal and parietal branches
Outer diameters were measured at the origin, 10 mm from the origin, 70 mm from the superior border of the ZA (working length, following Marano et al. [12]), and 100 mm from the ZA. Branch lengths from the ZA to the point at which the outer diameter declined to 1 mm were recorded. Angular measurements comprised: (a) the angle formed by each branch with a horizontal reference line (dx) passing through the branching point and parallel to the Ox axis; and (b) the parietal axis angle, as defined by Suanchan et al. [25]. A branch was considered suitable for cortical MCA bypass if its outer diameter was ≥ 1 mm at 70 mm from the ZA [12].
Measurement technique
Vessel outer diameter was measured using a standardised digital calliper by gently flattening the artery and measuring half the circumference; diameter was calculated from C = πd. In practice, the collapsed artery was laid flat without longitudinal stretching, and the width of the flattened vessel was measured at the defined level with the calliper jaws applied under minimal, reproducible pressure. This flattened width equals half of the outer circumference (the semi-circumference, C/2 = πd/2), so that the outer diameter was derived as d = (2 × flattened width)/π. This semi-circumference technique has been used consistently across the major cadaveric STA studies that form the basis of comparison in the present work [2, 12, 22], which facilitates direct numerical comparability. Regarding the potential effect of atherosclerotic mural calcification on vessel compliance in the older age group (mean 69.92 years): arteries with advanced medial calcification resist complete flattening, which could introduce a systematic overestimation of the circumference and hence of the calculated diameter. To mitigate this, all vessels with visible calcific plaques or those that could not be gently flattened without structural disruption were documented and would have been excluded from the corresponding diameter calculations. In the present sample, however, no vessel exhibited calcification or rigidity sufficient to prevent gentle flattening; accordingly, no specimen was excluded on this basis, and all 50 hemi-heads contributed to the diameter analyses (the effective denominator for each branch variable reflects branch presence and is stated in Tables 1 and 3). We nonetheless acknowledge in the Limitations that, had such vessels been present, their exclusion could have biased suitability estimates upward by preferentially removing less compliant conduits. This pre-measurement inspection step was incorporated to preserve the validity of the technique in an elderly sample. Branch lengths were measured by contouring a 3–0 Vicryl suture along the vessel and then measuring the straightened suture with a calliper. Angulations were measured with a standardised digital bevel protractor. All measurements were performed by two trained anatomists. To quantify inter-rater reliability, 20% of specimens (10 hemi-heads, selected by systematic random sampling) were independently re-measured by a second observer blinded to the initial values; intraclass correlation coefficients (ICC, two-way mixed model, absolute agreement) were calculated for all continuous variables.
Table 1.
Measurements of the common trunk of the STA by side
| Measurement | Left (n = 25) | Right (n = 25) | Test statistic | p value |
|---|---|---|---|---|
| Distance from origin to mandibular neck (mm) | 12.21 ± 5.56 | 10.59 ± 6.57 | U = 267.0 | 0.225a |
| Distance to tragus along OC line (mm) | 15.11 ± 5.59 | 16.46 ± 5.91 | U = 297.0 | 0.594a |
| Distance to tragus along OA line (mm) | 10.47 ± 3.48 | 11.37 ± 4.75 | U = 293.5 | 0.771a |
| Distance to superior helix attachment along AB line (mm) | 12.28 ± 5.31 | 13.41 ± 7.15 | U = 280.5 | 0.282a |
| Distance to STV1 (mm) | 2.97 ± 3.54 | 5.45 ± 3.58 | U = 192.0 | 0.008a* |
| Distance to ATN1 (mm) | 2.93 ± 2.81 | 3.65 ± 3.36 | U = 300.5 | 0.466a |
| Intra-parotid segment length (mm) | 29.54 ± 12.95 | 32.41 ± 14.75 | U = 296.0 | 0.607a |
| Extra-parotid segment length (mm) | 26.11 ± 11.52 | 25.57 ± 12.88 | t(48) = 0.15 | 0.881b |
| Diameter at origin (mm) | 2.26 ± 0.54 | 2.30 ± 0.51 | U = 293.5 | 0.771a |
| Diameter at parotid gland emergence (mm) | 2.05 ± 0.58 | 2.07 ± 0.43 | U = 311.0 | 0.915a |
| Diameter at superior border of ZA (mm) | 1.83 ± 0.45 | 1.92 ± 0.36 | U = 267.0 | 0.269a |
| Diameter immediately proximal to bifurcation (mm) | 1.68 ± 0.40 | 1.83 ± 0.31 | U = 243.5 | 0.066a |
1Measured at the level of parotid gland emergence. aMann–Whitney U test. bStudent’s t-test. *p < 0.05 (bold)
Table 3.
Measurements of the frontal and parietal branches by side
| Branch | Measurement | Left | Right | Test statistic | p value |
|---|---|---|---|---|---|
| Frontal | Diameter at origin (mm) | 1.53 ± 0.26 | 1.69 ± 0.28 | t(46) = −1.69 | 0.098a |
| Diameter at 10 mm from origin (mm) | 1.40 ± 0.31 | 1.55 ± 0.30 | t(46) = −1.58 | 0.119a | |
| Diameter at 70 mm from ZA (mm) | 1.21 ± 0.27 | 1.31 ± 0.21 | U = 244.0 | 0.142a | |
| Diameter at 100 mm from ZA (mm) | 0.98 ± 0.18 | 1.06 ± 0.17 | t(39) = −1.49 | 0.151b | |
| Length from ZA to 1-mm threshold (mm) | 82.28 ± 23.64 | 91.44 ± 21.74 | t(46) = −1.40 | 0.169b | |
| Angle with dx (°) | 33.94 ± 11.91 | 38.91 ± 17.87 | t(46) = −1.12 | 0.267b | |
| Parietal | Diameter at origin (mm) | 1.36 ± 0.36 | 1.49 ± 0.24 | U = 236.0 | 0.051a |
| Diameter at 10 mm from origin (mm) | 1.25 ± 0.27 | 1.37 ± 0.26 | t(45) = −1.58 | 0.119b | |
| Diameter at 70 mm from ZA (mm) | 1.05 ± 0.21 | 1.18 ± 0.20 | t(45) = −2.18 | 0.033b* | |
| Diameter at 100 mm from ZA (mm) | 0.87 ± 0.15 | 0.93 ± 0.21 | U = 198.5 | 0.753a | |
| Length from ZA to 1-mm threshold (mm) | 95.50 ± 33.40 | 100.61 ± 20.97 | t(45) = −0.63 | 0.533b | |
| Angle with dx (°) | 70.15 ± 17.11 | 77.96 ± 13.02 | U = 233.0 | 0.081a | |
| Parietal axis angle (°) | 74.79 ± 11.10 | 79.12 ± 9.90 | t(45) = −1.86 | 0.065b |
aMann–Whitney U test. bStudent’s t-test. *p < 0.05 (bold). Frontal branch n = 48; parietal branch n = 47 (specimens with the corresponding anaplastic pattern, in which the branch was absent, are excluded)
Statistical analysis
Data were analysed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables are expressed as mean ± SD with 95% confidence intervals (CI); categorical variables as absolute numbers and percentages. Normality was assessed with the Shapiro–Wilk test; homogeneity of variance with Levene’s test. Between-side comparisons used the Student’s t-test (normally distributed, equal variances) or the Mann–Whitney U test (otherwise). The test statistic (t or U) and degrees of freedom are reported alongside p values. Proportional differences were assessed by chi-square or Fisher’s exact test. Statistical significance was set at p ≤ 0.05 (two-tailed). Because the 50 hemi-heads derived from 25 individuals, the left and right sides are not fully independent. Between-side comparisons (Tables 1 and 3) were treated as the paired contrasts of interest; independent-samples tests were applied, which are generally more conservative than paired tests for positively correlated bilateral data, so the significant asymmetries reported here are unlikely to be artefacts of the analytic choice. For pooled (both-sides) descriptive morphometry, each hemi-head was treated as the unit of analysis given the side-specific relevance of STA anatomy to surgical planning; within-individual clustering is addressed in the Limitations (Figs. 1, 2 and 3).
Fig. 1.
Illustration relationship between common trunk and tragus on OC and OA lines and superior attachment to the scalp of the helix on AB line. O: midpoint of tragus, C: midpoint of inferior orbital border, A: lateral canthus, B: superior attachment of helix to the scalp. i: distance from common trunk to tragus on OC line, ii: distance from common trunk to tragus on OA line, iii: distances grom common trunk to superior attachment of helix on AB line (specimen 24 on left side – ID: 215/2018)
Fig. 2.
Illustration coordinates of terminal branching point in Oxy coordinate system. O: midpoint of tragus, Ox axis passes through midpoint of tragus (point O) and infra-orbital margin, Oy axis is perpendicular to Ox at point O, P: terminal branching point of STA (specimen 24 on left side – ID: 215/2018)
Fig. 3.
Illustration angles measurements identification. A. Angles between either frontal or parietal branch with dx line (specimen 24 on left side – ID: 215/2018). Ox: x-axis of Oxy coordinate system, dx: straight line passing through terminal branching point (point P) and parallel to Ox, α : angle formed by frontal branch and dx, ß: angle formed by parietal branch and dx. B. Parietal axis angle (λ ) (specimen 23 on right side – ID: 396/2025). O: midpoint of tragus, A: lateral canthus, White arrow: position of common trunk at superior border of ZA, Black arrow: intersection point of parietal branch and superior temporal line (yellow dotted line)
Results
Sample characteristics
The 25 cadavers comprised 12 females (48%) and 13 males (52%). Mean age at death was 69.92 ± 10.99 years (range 45–87 years). No significant difference in age was found between sexes (p = 0.094).
Measurement reliability
Inter-rater ICC values for all continuous diameter measurements ranged from 0.91 to 0.97 (95% CI 0.86–0.99), indicating excellent reliability. ICC values for length measurements ranged from 0.88 to 0.94 (95% CI 0.82–0.97), and for angular measurements from 0.85 to 0.92 (95% CI 0.79–0.96), both indicating good-to-excellent reliability. These results confirm that the semi-circumference measurement technique, as applied in the present study, yields highly reproducible measurements across observers for STA morphometric variables (Figs. 4, 5 and 6).
Fig. 4.
Illustration of parietal anaplastic cases. Left (specimen 06 on the right side – ID: 178/2016): Common trunk coursed anterosuperiorly and became the solitary frontal branch (white arrowheads). Right (specimen 12 on the right side – ID: 206/2017): Common trunk coursed anterosuperiorly and became the frontal branch with bifurcation (white star) into anterior (white arrow) and posterior branch (black arrow) at the level of superior temporal line. White four-way arrow: A. anterior; P. posterior; S. superior; I. inferior
Fig. 5.
Illustration another anaplastic parietal case (specimen 14 on the left side – ID: 242/2018): common trunk coursed anterosuperiorly and became frontal branch (white arrowheads). Upon passing the superior temporal line, frontal branch turned back and coursed posteriorly. Left: lateral view. White four-way arrow: A. anterior; P. posterior; S. superior; I. inferior. Right: obliquely from upper left view. White four-way arrow: A. anterior; P. posterior; L. left side; R. right side
Fig. 6.
Illustration of frontal anaplastic case (specimen 04 on the left side—ID: 177/2016): common trunk ran straight upward and became parietal branch (white arrowheads), whereas orbitozygomatic artery was dominant and high-riding. White four-way arrow: A. anterior; P. posterior; S. superior; I. inferior
Common trunk of the STA
The STA originated posterior to the mandibular neck in all 50 specimens. Mean distance from the STA origin to the mandibular neck was 11.40 ± 6.08 mm. Mean outer diameters at the origin and at parotid gland emergence were 2.28 ± 0.52 mm and 2.06 ± 0.50 mm, respectively.
At the level of parotid gland emergence, the common trunk was anterior to the STV in 43 specimens (86%) and posterior in 7 (14%); anterior to the ATN in 33 (66%) and posterior in 17 (34%). Mean distances between the common trunk and the STV and ATN were 4.21 ± 3.74 mm and 3.30 ± 3.09 mm, respectively.
Along the OC line, the common trunk was 15.78 ± 5.74 mm (95% CI 14.30–17.41 mm) anterior to the tragus. Along the OA line, this distance was 10.92 ± 4.14 mm (95% CI 9.83–12.56 mm). The mean distance from the common trunk to the superior helix attachment along AB was 12.85 ± 6.26 mm (95% CI 11.48–14.57 mm). Mean intra-parotid and extra-parotid segment lengths were 30.98 ± 13.82 mm and 26.30 ± 12.13 mm. Mean outer diameters at the ZA level and immediately proximal to bifurcation were 1.88 ± 0.40 mm and 1.76 ± 0.36 mm. No statistically significant bilateral asymmetry was detected except for the STA–STV distance (Table 1).
Terminal branching patterns and branching point position
Four branching patterns were identified (Table 2; Fig. 7); types A2 and A3 were not observed. No significant bilateral difference in pattern frequency was detected (Fisher’s exact test, p = 0.545). In five specimens with anaplastic patterns (types B1 or B2), the terminal branching point was absent. Among the remaining 45 specimens, the branching point was above the ZA in 42 (93.33%), at the ZA in 2 (4.44%), and below the ZA in 1 (2.22%). Mean Oxy coordinates were X = 17.60 ± 8.73 mm and Y = 40.22 ± 15.91 mm.
Table 2.
Terminal branching patterns of the STA (n = 50)
| Type | Description | n (%) |
|---|---|---|
| A1 | Classic: bifurcation into frontal and parietal branches, both with origin diameters ≥ 1 mm | 44 (88) |
| A4 | Hypoplastic both branches: bifurcation with both branch diameters < 1 mm at origin | 1 (2) |
| B1 | Anaplastic parietal branch: no bifurcation; common trunk continues anterosuperiorly to become the frontal branch | 3 (6) |
| B2 | Anaplastic frontal branch: no bifurcation; common trunk continues posterosuperiorly to become the parietal branch | 2 (4) |
Fig. 7.
Schematic of the four terminal branching patterns of the STA observed in the present series (n = 50 hemi-heads), classified after Marano et al. [12]. Type A1 (classic bifurcation; 88%): the common trunk divides into a frontal (F) and a parietal (P) branch, both ≥ 1 mm at origin. Type A4 (hypoplastic both; 2%): bifurcation with both branches < 1 mm at origin. Type B1 (anaplastic parietal; 6%): no bifurcation, the common trunk continues anterosuperiorly as a solitary frontal branch. Type B2 (anaplastic frontal; 4%): no bifurcation, the common trunk continues posterosuperiorly as a solitary parietal branch. The dashed line marks the zygomatic arch (ZA); the dotted line marks the 70-mm working length from the ZA, at which a branch outer diameter ≥ 1 mm was required to qualify as a suitable cortical MCA bypass conduit. Line thickness denotes relative branch calibre. Types A2 (hypoplastic parietal) and A3 (hypoplastic frontal) were not observed
Frontal branch
Mean outer diameters at the origin and at 10 mm from the origin were 1.61 ± 0.33 mm and 1.47 ± 0.31 mm, respectively. At the 70-mm working length from the ZA, mean diameter was 1.26 ± 0.25 mm; at 100 mm, 1.02 ± 0.18 mm. Mean length from the ZA to the 1-mm threshold was 87.05 ± 22.90 mm. At the 70-mm working length from the ZA, the frontal branch met the suitability criterion (outer diameter ≥ 1 mm) in 88.0% of all specimens on an intention-to-treat basis (44/50) and in 91.7% of specimens in which a frontal branch was present (44/48; per-protocol). At 100 mm from the ZA, the intention-to-treat suitability rate was 36.0% (18/50). Mean angle with the dx line was 36.53 ± 15.36°. No significant bilateral asymmetry was found (Table 3).
Parietal branch
Mean outer diameters at the origin and at 10 mm from the origin were 1.43 ± 0.26 mm and 1.31 ± 0.37 mm, respectively. At 70 mm from the ZA, mean diameter was 1.11 ± 0.22 mm; at 100 mm, 0.91 ± 0.18 mm. Mean length from the ZA to the 1-mm threshold was 98.00 ± 27.84 mm. At the 70-mm working length, the parietal branch met the suitability criterion in 68.0% of all specimens on an intention-to-treat basis (34/50) and in 72.3% of specimens in which a parietal branch was present (34/47; per-protocol). At 100 mm, the intention-to-treat rate was 18.0% (9/50). Mean angle with the dx line was 74.82° ± 15.50°; mean parietal axis angle was 75.96° ± 11.49°. The right parietal branch diameter at 70 mm was significantly greater than the left (p = 0.033); no other bilateral asymmetry was significant (Table 3).
Bypass suitability
On an intention-to-treat basis (denominator = all 50 hemi-heads), the frontal branch, the parietal branch, or both branches simultaneously were suitable for cortical MCA bypass in 88.0% (44/50), 68.0% (34/50), and 62.0% (31/50) of specimens, respectively. When restricted to specimens in which the relevant branch was present (per-protocol), the corresponding rates were 91.7% (44/48) for the frontal branch, 72.3% (34/47) for the parietal branch, and 68.9% (31/45) for both branches. We adopt the intention-to-treat denominator as the primary reference because branch absence (anaplastic patterns) itself determines conduit availability and is therefore directly relevant to pre-operative planning; per-protocol rates are provided for comparability with series reporting only branch-present specimens. Results are compared with published series in Table 4.
Table 4.
Frequencies of terminal branches suitable for cortical MCA bypass across studies
| Study | Frontal branch, n (%) | Parietal branch, n (%) | Both branches, n (%) |
|---|---|---|---|
| Marano et al. [12] (n = 50, cadaveric) | 45 (90) | 36 (71.4) | N/A |
| Pinar et al. [22] (n = 27, cadaveric) | 24 (89) | 21 (78) | N/A |
| Kim et al. [9] (n = 70, CTA) | 53 (75.7) | 46 (66.7) | 33 (47.1) |
| Current study (n = 50, cadaveric) | 44 (88) | 34 (68) | 31 (62) |
CTA computed tomography angiography; N/A not available. Suitability rates for the current study are expressed on an intention-to-treat basis (denominator = 50 hemi-heads)
Discussion
In the present study, we characterised the topographic and morphometric anatomy of the STA in Vietnamese adult cadavers with specific reference to STA–MCA bypass surgery. The direct STA–MCA bypass was first described by Yaşargil et al. [28] in 1967 and remains the standard revascularisation procedure for Moyamoya disease [5, 7]. Multiple series have confirmed the safety and efficacy of this technique [8, 14, 15, 18, 19, 30].
Pre-operative surface mapping of the STA is critical for incision planning and for avoiding inadvertent vessel injury during the craniotomy approach. In the present study, the mean distances from the common trunk to the tragus along the OA and OC lines (10.92 mm and 15.78 mm, respectively) and to the superior helix attachment (12.85 mm) were closely concordant with the values reported by Chen et al. [2] in a Chinese cadaveric series (OA: 11.40 mm; AB: 12.20 mm), but substantially lower than those of Ahmed et al. [1] and Pinar et al. [22] in European cadavers (OA: ~16.68 to 16.69 mm; AB: ~20 mm; Table 5). This discrepancy is consistent with the smaller craniofacial dimensions characteristic of Southeast Asian populations.
Table 5.
Distance from the common trunk of the STA to the tragus and to the superior helix attachment across studies
| Study | Distance to tragus along OA line (mm) | Distance to superior helix attachment along AB line (mm) |
|---|---|---|
| Chen et al. [2] (n = 52, cadaveric) | 11.40 ± 3.20 | 12.20 ± 7.90 |
| Ahmed et al. [1] (n = 28, cadaveric) | 16.69 ± 0.36 | 20.03 ± 0.56 |
| Pinar et al. [22] (n = 27, cadaveric) | 16.68 ± 0.35 | 20.01 ± 0.54 |
| Current study (n = 50, cadaveric) | 10.92 ± 4.14 (95% CI 9.83–12.56) | 12.85 ± 6.26 (95% CI 11.48–14.57) |
On the basis of the lower 95% CI boundary for the OA-line distance, we recommend that the anterior margin of the skin incision should not extend beyond 9 mm anterior to the tragus along the OA line, nor beyond 11 mm anterior to the superior helix attachment along the AB line. These landmark-based recommendations derive from anatomical observations in the present Vietnamese cadaveric sample and are intended to complement–not replace–individualised intra-operative assessment and pre-operative vascular imaging (e.g., CT angiography or Doppler ultrasound). It should be noted that all measurements were performed with the cadaver in the standard anatomical position; surgeons should be aware that head rotation on the operating table may shift soft-tissue landmarks relative to the underlying STA. Regarding the STA–STV relationship, the STV lay posterior to the STA in the majority of specimens, with the mean inter-vessel distance significantly greater on the right than the left (5.45 mm vs. 2.97 mm; p = 0.008), implying a narrower protective margin during left-sided dissection. We therefore recommend systematic Doppler identification of the superficial temporal vein before skeletonisation of the STA on the left side, where the reduced venous separation increases the risk of inadvertent venous injury. With respect to nerve preservation, the common trunk lay posterior to the auriculotemporal nerve in 34% of specimens, with a mean inter-structure distance of only 3.30 ± 3.09 mm and a high coefficient of variation, indicating that the nerve may lie immediately adjacent to the artery in a substantial subset. Careful identification and preservation of the auriculotemporal nerve during intra-parotid STA harvest is therefore advised to avoid auriculotemporal (Frey-type) syndrome.
The mean diameter of the common trunk at the ZA level (1.88 ± 0.40 mm) was lower than all comparative cadaveric studies (Table 6). The most plausible explanation is vessel wall contraction secondary to prolonged formalin fixation (mean 6.3 years), which induces collagen cross-linking and smooth muscle dehydration in both the tunica media and adventitia. Importantly, in the absence of in vivo CTA or DSA data from the same Vietnamese population, it is not scientifically justifiable to apply a speculative correction factor to the observed suitability rates. The suitability figures reported here—88% for the frontal branch and 68% for the parietal branch at the 70-mm working length—should therefore be interpreted as conservative estimates that may underestimate true in vivo suitability. Readers and surgeons should bear this caveat in mind when applying these data to clinical decision-making. The acquisition of paired in vivo angiographic data from Vietnamese adults represents a priority for future research.
Table 6.
Outer diameter of the common trunk at the level of the zygomatic arch across cadaveric studies
The classic bifurcation pattern (type A1) was present in 88% of specimens, consistent with the predominance of this variant across published series (Table 7). Marano et al. [12] originally reported 70% in their classification study; subsequent cadaveric and radiological series report rates of 66–97% [1, 13, 16, 22, 29]. The frequencies of anaplastic frontal (4%) and parietal (6%) branches in the current series fall within the published range. Notably, the CT angiographic series of Rusu et al. [23] reported a considerably higher rate of parietal-branch absence (25.6% of STAs; 16.3% unilateral and 9.3% bilateral) than the 6% observed here, a difference likely reflecting imaging-versus-dissection ascertainment and population variation. With respect to the level of termination, Rusu et al. [23] found that 87% of bifurcating STAs terminated above the posterior root of the zygomatic arch, closely matching our value of 93.33%. Although the present study confirmed that the STA arose posterior to the mandibular neck in all specimens (mean 11.40 ± 6.08 mm), we did not characterise its subsequent pericondylar course; this topography is relevant to lateral temporomandibular joint procedures–Rusu et al. [23] documented a laterocondylar STA in 13.6% of bilaterally symmetrical cases and in up to 37% of patients on at least one side–and readers are directed to that study for this variant. Specific features of the anaplastic cases are described in the figure legends. A surgical case report by Tokugawa et al. [27] illustrates that even in the absence of a suitable STA branch, successful MCA bypass can be achieved using alternative donor vessels (posterior auricular artery).
Table 7.
Frequencies of terminal branching patterns across studies
| Study | Classic, n (%) | Hypoplastic both, n (%) | Anaplastic frontal, n (%) | Anaplastic parietal, n (%) |
|---|---|---|---|---|
| Marano et al. [12] (n = 50, cadaveric) | 35 (70) | 1 (2) | 1 (2) | 3 (6) |
| Ahmed et al. [1] (n = 28, cadaveric) | 27 (96.43) | N/A | N/A | 1 (3.57) |
| Pinar et al. [22] (n = 27, cadaveric) | 18 (66.67) | N/A | 6 (22.22)1 | 3 (11.11)1 |
| Mwachaka et al. [16] (n = 30, cadaveric) | 28 (93.33) | N/A | N/A | N/A |
| Yücedağ Gündoğdu et al. [29] (n = 417, CTA) | 405 (97.12) | 1 (0.24) | 55 (13.19) | 3 (0.72) |
| Medved et al. [13] (n = 93, DSA) | 45 (48.39) | 5 (5.30) | 9 (9.70) | 1 (1.10) |
| Pham et al. [21] (n = 45, cadaveric) | 43 (95.56) | N/A | 1 (2.22) | 1 (2.22) |
| Rusu et al. [23] (n = 86, CTA) | N/A | N/A | N/A | 22 (25.6)2 |
| Current study (n = 50, cadaveric) | 44 (88) | 1 (2) | 2 (4) | 3 (6) |
1In Pinar et al. [22], hypoplasia was defined as original branch diameter < 1.5 mm. CTA computed tomography angiography; DSA digital subtraction angiography; N/A not available.
2Rusu et al. [23] reported parietal-branch absence in 25.6% of STAs (16.3% unilateral, 9.3% bilateral) on CTA; classic, hypoplastic, and anaplastic-frontal frequencies were not reported in a directly comparable format
The mean angles of the frontal and parietal branches with the dx line (36.53° and 74.82°) are consistent with 27.93° and 87.07° reported by Hardy et al. [4] using head CTA; the small discrepancy likely reflects their use of the lateral canthus–tragus line rather than the infra-orbital margin–tragus line as the reference axis. The mean parietal axis angle in the present study (75.96° ± 11.49°; 95% CI 71.97°–80.39°) was lower than the 88.8° (75°–95°) reported by Suanchan et al. [25] in a Thai population. As the upper 95% CI boundary in the current study (80.39°) lies near the lower end of the range reported by Suanchan et al. (75°–95°), we recommend placing the modified pterional incision posterior to 80° of the parietal axis angle in Vietnamese patients, a position that is more anterior than Suanchan et al.’s recommendation and reflects the narrower STA-free zone in this population.
Terminal branch diameters at origin and at 10 mm from origin in the present study were lower than most comparative series (Table 8), consistent with the fixation-related shrinkage discussed above. Despite this, bypass suitability at the working length of 70 mm was comparable to published values (Table 4). Mean lengths to the 1-mm threshold (87.05 mm for FB; 98.00 mm for PB) were shorter than those reported by Marano et al. [12] (99.2 mm and 106 mm, respectively), suggesting that in Vietnamese patients a bypass to a proximal MCA segment (M3) may occasionally be required. Lee et al. [10] reported 100% early patency with STA-to-M3 bypass in six patients with complex internal carotid artery aneurysms, supporting the feasibility of this alternative.
Table 8.
Outer diameters of frontal and parietal branches across studies
| Study | FB origin (mm) | FB 10 mm (mm) | FB 70 mm (mm) | PB origin (mm) | PB 10 mm (mm) | PB 70 mm (mm) |
|---|---|---|---|---|---|---|
| Tayfur et al. [26] (n = 26) | 1.8 | N/A | N/A | 2.0 | N/A | N/A |
| Chen et al. [2] (n = 52) | N/A | 1.61 ± 0.19 | N/A | N/A | 1.68 ± 0.21 | N/A |
| Pinar et al. [22] (n = 27) | N/A | 2.14 ± 0.54 | N/A | N/A | 1.81 ± 0.45 | N/A |
| Pham et al. [21] (n = 45) | 1.51 ± 0.32 | N/A | N/A | 1.82 ± 0.48 | N/A | N/A |
| Current study (n = 50) | 1.61 ± 0.33 | 1.47 ± 0.31 | 1.26 ± 0.25 | 1.43 ± 0.26 | 1.31 ± 0.37 | 1.11 ± 0.22 |
FB, frontal branch; N/A, not available; PB, parietal branch
The right parietal branch diameter was significantly larger than the left at 70 mm from the ZA (p = 0.033), consistent with Manoli et al. [11], who found a significantly larger right parietal diameter at the proximal bifurcation by DSA, with no bilateral difference in frontal diameter or in branch lengths—findings fully concordant with the present series.
A significant consideration for clinical applicability is the discordance between the age of the study sample (mean 69.92 years) and the demographic profile of the primary target population for STA–MCA bypass. Moyamoya disease characteristically presents in two peak incidence windows: childhood (5–10 years) and early-to-mid adulthood (35–50 years) [7]. Atherosclerotic and arteriosclerotic changes accumulate with advancing age, causing progressive intimal hyperplasia, medial hypertrophy, and reduced vessel compliance. These changes would be expected to reduce STA calibre and wall distensibility relative to younger individuals. Consequently, the diameter measurements and suitability rates reported in the present study may be lower than would be observed in the younger Moyamoya patient population—reinforcing the interpretation that the suitability figures (88% for FB; 68% for PB) are likely conservative estimates rather than overestimates. For other indications of STA–MCA bypass where patients are typically older (atherosclerotic carotid occlusion, complex aneurysm management), the age of the present sample is more representative. Future studies specifically enrolling younger cadaveric donors, or obtaining in vivo CTA data from Vietnamese patients with Moyamoya disease, are needed to better characterise the donor vessel anatomy in the most common bypass indication.
The present study has several limitations that must be acknowledged. First, the exclusive use of long-term embalmed cadavers (mean 6.3 years) introduces a systematic underestimation of vessel diameters, as discussed above; suitability rates should be regarded as conservative lower-bound estimates pending in vivo validation. Second, the specimens were derived from a single geographic region (Ho Chi Minh City), which may limit generalisability to other Vietnamese subpopulations. Third, the mean donor age (69.92 years) differs substantially from the Moyamoya disease patient population; age-related vascular changes in the study sample may further contribute to the lower diameters observed. Fourth, regarding surface mapping landmarks: the superior helix attachment (point B) is a soft-tissue landmark that is susceptible to displacement when the head is rotated on the operating table. Intra-operative head rotation of 30°–45° (typical for pterional approaches) can shift the pinna superiorly and anteriorly by several millimetres, altering the actual AB-line distance relative to the underlying STA. Surgeons should account for this displacement and, where feasible, confirm STA position using intra-operative Doppler ultrasound rather than relying exclusively on the surface mapping coordinates established in the standard anatomical position. Fifth, the absence of pre-mortem imaging data precluded direct in vivo–post-mortem morphometric correlation. Future studies combining cadaveric dissection with CTA or DSA data from Vietnamese adults, incorporating a formal quantification of the embalming-induced shrinkage factor, would greatly enhance the translational value of the present findings. Sixth, we did not quantify kinking or coiling of the STA, which bear directly on usable conduit length, donor-vessel geometry, and flow near the anastomosis; CT angiographic data have documented kinking in more than 85% and coiling in approximately 6% of STAs [23], and cadaveric dissection may under-represent in vivo kinking if vessels relax after fixation. Seventh, because the two sides of each donor are not fully independent, the pooled confidence intervals may be marginally narrower than a mixed-effects (multilevel) model would yield; future pooled analyses would benefit from such an approach.
Conclusion
In Vietnamese adults, the STA bifurcated into frontal and parietal branches in 90% of specimens, with the terminal branching point predominantly above the zygomatic arch, and the common trunk followed a consistent, reproducibly mappable course anterior to the tragus and to the superior helix attachment. On an intention-to-treat basis, the frontal branch, the parietal branch, or both were suitable for cortical MCA bypass in 88%, 68%, and 62% of specimens, respectively, at the 70-mm working length. Overall, STA anatomy in this population is favourable for STA–MCA bypass, and the surface-mapping landmarks reported here provide a practical, population-specific basis for pre-operative planning that should complement, rather than replace, intra-operative assessment and vascular imaging.
Acknowledgements
The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase mankind’s overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.
Abbreviations
- ATN
Auriculotemporal nerve
- CTA
Computed tomography angiography
- DSA
Digital subtraction angiography
- FB
Frontal branch
- MCA
Middle cerebral artery
- PB
Parietal branch
- STA
Superficial temporal artery
- STV
Superficial temporal vein
- ZA
Zygomatic arch
Author contributions
Vu Hoang Nguyen: Project development, data collection, data analysis, manuscript writing/editing Phuong; Duy Nguyen: Project development, data collection, data analysis, manuscript writing/editing; Dieu Dang Pham: Project development, data collection, manuscript writing/editing; Tuyen Quang Le: Project development, resources, manuscript writing/editing.
Funding
This study has no funding.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Conflict of interest
The authors have no relevant financial or non-financial interests to disclose.
Ethical approval
This study was performed in accordance with the Declaration of Helsinki. Approval was granted by the Institutional Review Board of the University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (No. IRB-VN01002/IRB00010293/FWA00023448).
Consent to participate
Not applicable (cadaveric study).
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Tuyen Quang Le and Vu Hoang Nguyen contributed equally to this work.
Dieu Dang Pham and Tuyen Quang Le contributed equally to this work.
Contributor Information
Phuong Duy Nguyen, Email: ndphuong.ncs.gph23@ump.edu.vn.
Vu Hoang Nguyen, Email: vunguyen@ump.edu.vn.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.